capline dental services

Pre-authorization Vs. Pre-determination

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Pre-authorization and pre-determination can create confusion for even the savviest of professionals. Is  there a difference between them? Digging a little deeper into both can benefit any practice in filing dental claims without  any difficulty to remain profitable. For your daily financial management, ensure that you understand  the importance of pre-authorization & pre-determination. 

What is Pre-authorization? 

Pre-authorization is a process that requires written advance approval for the rendered service. In the  realm of insurance, it comes into the picture when the patient is unsure about their insurance plan &  its coverage and fails to obtain the necessary reasons in the case of denied payment. The validity for pre-authorization is 60 days. Typically, by submitting a pre-authorization treatment claim, you are saving yourself and your patient from the trouble of rejected claims and unexpected co-pays & deductibles. 

In essence, pre authorization also includes other additional elements like radiographs, diagnostic notes, x-rays, narratives, procedure codes, periodontal charting, etc., to ensure if those services are medically  necessary. Treatments such as root planning, scaling, etc., require pre-authorization to determine the  patient’s payment portion. In the world of dental billing, pre-authorization helps establish trust and  helps protect your office’s income. Furthermore, it also depends on the policy plan and state laws. 

Some plans recommend obtaining pre-authorization, such as Medicaid, Medicare and managed care  plans. However, if the beneficiary exhausts the annual maximum limit, leaves the insurance plan  before the treatment, or duplicates a claim for the same treatment from a different dentist, the claim for that plan can be rejected and the can be downgraded as well. 

What is Pre-determination? 

Pre-determination is also known as pretreatment estimate or pre-estimate of benefits. Therefore,  ultimately, it is a way to view individual plan specifics and see the transparency of cost. It is a  formal inquiry of a patient’s coverage and eligibility and at the same time does not give a guarantee of reimbursement. Unlike  pre-authorizations, pre-determinations are a trade-off for dentists with patients thinking that the dentist’s cost is more painful than the treatment. Every individual’s financial situation is different. Hence pre-determination can provide a written estimate for the desired treatment. Pre-determination caveats leave time for patients to forget or reconsider the  rendered treatment. In addition to estimating the out-of-pocket expense, pre-determination helps assert that the beneficiary is indeed a covered enrollee in the plan. 

Many insurance companies do not consider pre-determination as a promise to cover the cost of care  especially in the case of discrepancies. It is used to support the documentation such as exclusions, limitations,  enrollee eligibility on the treatment date, and coordination of benefits before providing any  treatment or else these things become solely the patient’s responsibility. A significant downside on pretreatment estimates is that  the patient will go untreated, hampering your dental practice’s income. On one hand, it is a  helpful financial tool when it comes to estimation. On the other hand, stopping the cash flow for obtaining pre-determination from the insurer can often take upto two to six weeks.  

Using Pre-determination a breakthrough in your practice 

The world of dental billing is volatile yet profitable if handled appropriately. Here are a few ways to  avoid guesswork in financing. 

Educating Patients: 

Train your staff to educate patients about their plan and how costly procedures such as crowns can  fit into their wallets along with dental care. Through information literacy, your office can have a steady acceptance rate for the treatment plan. By educating them, you will gain their trust when  they are ready to schedule an appointment. 


Practitioners juggle between recare and operative visit thinking how to schedule for  profitably. Firstly, consider recare appointment and then the operative one after a few weeks as you will still have the time for pre-determination. Secondly, wait to schedule the operative visit until  authorization as it can help patients get immediate care. 

For same-day treatment: 

For the same-day treatment, you can receive pre-determination on the phone. Though not  recommended, as written one is a more accurate confirmation that you can get on the insurer’s website.  This means that the patient knows approximate prices of what he/she is responsible for and what the  insurer will pay.